Medical Assistant - Care Navigator

ProviDRs Care•Wichita, KS

54d•Onsite

About The Position

We are seeking a motivated and highly organized Medical Assistant – Care Navigator to join our Integrated Health Management team. This is a unique opportunity for a Medical Assistant who wants to expand beyond the traditional clinic setting and work within the health plan and care management environment. Our Care Navigators help members understand and access their healthcare resources while working closely with RN Case Managers, Utilization Review Nurses, Customer Service, Network Operations, healthcare providers, and other internal and external partners. The Care Navigator assists with member outreach, care coordination, Centers of Value placement, provider steerage, Case Management intake, utilization review support, population health data review, medical record retrieval, DME coordination, and employer-group reporting. This position works within a collaborative department led by a Supervisor, Manager, and Director of Integrated Health Management.

Requirements

High school diploma or equivalent.
Completion of a Medical Assistant training program.
Knowledge of basic medical terminology.
Strong computer skills and ability to learn multiple healthcare software systems.
Excellent verbal and written communication skills.
Strong organizational skills and attention to detail.
Ability to manage multiple priorities in a fast-paced environment.
Ability to communicate professionally with members, healthcare providers, and internal departments.
Ability to maintain confidentiality and appropriately handle protected health information (PHI).

Nice To Haves

Certified or Registered Medical Assistant (CMA, RMA, CCMA, or equivalent).
At least one year of healthcare experience.
Previous experience with patient/member outreach or care coordination.
Experience working with health insurance, a health plan, TPA, provider network, population health, prior authorization, utilization management, or Case Management.
Experience requesting and reviewing medical records.
Experience working with healthcare data, reports, or electronic health information systems.

Responsibilities

Help members navigate healthcare services, providers, facilities, and available health plan resources.
Assist members in locating appropriate in-network and cost-effective providers and facilities.
Coordinate placement of eligible members at designated Centers of Value (COV) for certain procedures and services.
Perform provider and facility steerage according to established health plan and network guidelines.
Help identify and resolve barriers that may prevent members from accessing appropriate healthcare services.
Assist members with obtaining durable medical equipment (DME), supplies, and other healthcare resources.
Conduct outbound member outreach and follow-up calls.
Provide ongoing follow-up to designated low-risk members according to established protocols.
Complete initial intake calls for members enrolling in Case Management.
Gather demographic, medical, medication, provider, social, and other information needed by the RN Case Manager.
Educate members about the Case Management program and available resources.
Coordinate or schedule follow-up with the RN Case Manager.
Assist RN Case Managers with provider outreach, medical records, appointment coordination, and other care coordination activities.
Identify changes or concerns during member interactions and escalate them to an RN when appropriate.
Monitor designated precertification/prior authorization email inboxes and voicemail queues.
Route incoming authorization requests and clinical documentation to the appropriate Utilization Review Nurse.
Assist with obtaining medical records and missing documentation needed for utilization review.
Contact provider offices and facilities regarding outstanding records or administrative information.
Track pending requests and follow up on outstanding documentation.
Recognize urgent or time-sensitive requests and escalate them promptly to the appropriate UR Nurse.
Review Clinigence and other population health and utilization data to identify members who may benefit from outreach or additional support.
Review designated diagnosis, utilization, high-cost, and other trigger reports according to established criteria.
Research identified members using available systems and determine the appropriate workflow or referral based on established guidelines.
Refer potentially high-risk, high-cost, or clinically complex members to the appropriate RN for review.
Track referrals, outreach attempts, interventions, and outcomes.
Request medical records and clinical documentation from physician offices, hospitals, facilities, and other healthcare providers.
Follow up on outstanding medical record requests.
Coordinate with providers and facilities regarding administrative and care coordination needs.
Route clinical documentation to the appropriate RN or department for review.
Assist with preparing routine and ad hoc reports for self-funded employer health plans.
Compile and validate Care Navigation, Case Management, utilization, outreach, steerage, and program activity data.
Assist with departmental KPI and performance reporting.
Research discrepancies and help ensure information is accurate before reports are finalized.
Maintain confidentiality of member and employer information.
Collaborate with Network staff on provider research, member access issues, provider availability, and steerage opportunities.
Research provider participation and network status using available systems.
Assist with provider outreach and special network initiatives.
Support Customer Service Representatives with questions related to Care Navigation, Case Management, Centers of Value, provider steerage, and departmental processes.
Assist Customer Service or Network Operations with additional duties during periods of increased volume or as business needs require.